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Nose & Sinuses- OSCE  

Leader: Maha Al lhaidan

Done by:

Arwa Almashaan Reem Aljubab

Shaikha AlDossari Tahani AlShaibani

Lama Alotaibi Hind almuhaya Reem Alhefdhi

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   Nose Examination ………………………3 Nasal block history …………………….5 Sinusitis…………………………………9 Epistaxis history ……………………….12 Rhinitis history …………………………14  

 

CONTENTS:

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Examination  of  Nose  and  Paranasal  Sinuses   Comment  Pre-­‐Exam  

Wash  hands    Introduce  your  self      Explain  the  procedure  and  take  Permission      Privacy      Position  of  physician  in  front  of  the  patient  and  the  patient  position  sitting  up  right    

 

Exposure  -­‐  Face   Mention  that  a  chaperone  should  be  present  if  examining  the  opposite  sex.  

General  Appearance  Appearance:  age/consciousness  /alertness  /distress.  Whistling  while  breathing  (perforation)  

Difficulty  in  breathing  or  breathing  from  the  mouth  

Body  built:  Normal  -­‐  thin  -­‐  obese    

Connections:  IV  lines  /  mask  /monitors     Use  of  inhalers  and  nebulizers  (indicates  asthma)  Color:  Pallor  -­‐  Jaundice  -­‐  cyanosis    

Vital  Signs  Pulse  Rate,  Respiratory  Rate,  Blood  Pressure,  and  Temperature    

Must  be  mentioned  

Inspection  1. External  Nose    

a. Size  of  the  nose  in  relation  to  the  rest  of  the  face      b. Deviation  of  bridge  of  nose     Stand  behind  the  Pt.  and  ask  him  to  look  upward,  

look  down  the  nose  from  above  to  detect  any  deviation  

c. Convexity  (hump)  or  concavity  (saddling)  of  the  dorsum  of  the  nose    

From  the  side  of  the  patient,  look  for  hump  or  saddle  nose  

d. Shape  of  the  tip  of  nose  (e.g.  pointed,  bulbous)      e. Shape  of  the  columella  and  nostrils  (short/wide  

columella,  narrow  /  wide  nostrils)      

f. Deviation  of  the  nasal  septum     (may  be  evident  in  one  nostril)  g. Skin  lesion:  for  swelling,  sinus,  bruising,  erythema  or  

ulceration    

2. Patency  test:  occlude  each  nostril  in  turn  with  your  thumb  and  ask  the  patient  to  exhale  in  front  a  shiny  surface  (e.g.  cold  meta  tongue  depressor)  Look  for  cloudiness  due  to  condensation  of  water  vapor  

3. Anterior  rhinoscopy  (inspection  from  anterior  nares  )  +  Light  Source  Before  using  nasal  speculum,  inspect  the  anterior  nares  and  nasal  vestibule  (that  may  otherwise  be  covered  up  by  the  blades  of  a  nasal  speculum)  by  pressing  on  the  tip  of  the  nose  to  elevate  it.    

-­‐  Look  for  asymmetry  -­‐  Notice  any  unpleasant  smell  -­‐  Check  the  color  of  the  nasal  discharge  and  if  suspecting  a  bacterial/fungal  infection  (greenish/grayish)  swab  and  send  for  culture  

Hold  the  nasal  speculum  in  the  left  hand  in  closed  fashion  and  introduce  it  gently  in  skin  lined  nasal  vestibule  with  one  limb  facing  downwards  and  other  upwards.    

Avoid  contact  with  the  sensitive  septum  and  lateral  nasal  wall  

  Nose Examination

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Open  the  speculum  gently  in  vestibule  and  examine  floor,  medial  wall  and  lateral  wall.    

Look  for  hyperemia,  hydration,  discharge  ulceration  in  Little's  area  (Kiesselbach's  area  is  a  region  in  the  anteroinferior  part  of  the  nasal  septum  where  four  arteries  anastomose),  septal  deviation  or  perforation,  hypertrophic  turbinates  or  polyps  (if  any).  Roof  as  such  cannot  be  examined  (it  needs  endoscopy)  

4. Make  a  habit  to  place  all  used  instrument  outside  your  instrument  case.  Disposable  instruments  should  be  discarded.  Non-­‐disposable  should  be  sterilized.    

Palpation    Palpation  of  the  Nose  

a. Press  along  the  bridge  of  the  nose  with  both  index  fingers  feeling  bony  skeleton  and  skin  thickness.    

To  distinguish  bony  from  cartilaginous  deformity)  

b. Press  on  the  tip  of  the  nose  with  one  index  finger  to  elicit  tenderness  

 

Palpation  of  Paranasal  Sinuses  for  Tenderness  (in  acute  sinusitis)  a. For  maxillary  sinus,  press  on  the  cheek  at  the  level  of  

canine  fossa  (see  the  figure  below)    

b. For  ethmoidal  sinus,  press  with  index  finger  between  medial  canthus  and  lateral  nasal  wall    

 

c. For  frontal  sinus,  press  just  below  the  medial  aspect  of  the  eyebrows  in  upward  direction  

 

Systemic  Review    Mention  that  you’d  like  to  use  the  flexible  fiberoptic  nasolaryngoscope  after  obtaining  the  patient  consent  and  decongesting  and  anesthetizing  the  nose  to  get  a  better  view  Mention  that  you  must  do  a  complete  ENT  examination  and  that  you’ll  check  the  olfactory  nerve.  

Post-­‐Exam  Thank  the  patient     Ask  if  he/  she  has  any  questions  or  

concerns      Cover  the  Patient    Wash  hands    Summarize  findings    

 Recommended  video  :  https://www.youtube.com/watch?v=AlZ0NXklaLw        

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 Items  

Introduction  Personal  data  Chief  complaint  History  of  presenting  Illness  (HPI)  Site  unilateral  (suggesting  structural  causes)  or  bilateral  (suggesting  mucosal  causes)  Onset  &  Duration  Pattern,  progression,  pain,  previously    Intermittent  with  respect  to:  -­‐Daily  time  course  -­‐Body  position  -­‐Seasonality  -­‐Exposures  to  environmental  stimuli  (eg,  cigarette  smoke,  particulate  matter,  pets,  chemicals)  Aggravating  and  Reliving  factors    Time  course  -­‐Temporal  course  of  symptoms,  including  diurnal  and  seasonal  variation  suggesting  an  allergic  process.  -­‐Nasal  septal  deviation  or  bony  inferior  turbinate  hypertrophy  typically  worsen  slowly  over  time.  Recent:  URTI,  Hx  of  sinusitis,  or  use  of  topical  nasal  decongestants  >5  days.  Samter’s  triad  (nasal  polyps,  aspirin  sensitivity,  asthma)  Severity  Associated  symptoms                    -­‐          Changes  in  sense  of  taste  and  smell  (hyposmia)  

-­‐          Persistent  postnasal  drip      -­‐          Symptoms  suggesting  malignancy:  Facial  deformity,  cranial  nerve  dysfunction  (eg,  facial  numbness),  and  unexplained  epistaxis,  middle  ear  effusion  (nasopharyngeal  ca)        -­‐          Symptoms  of  rhinosinusitis:  Facial  pain  or  pressure,  nasal  congestion,  dysosmia,  headache,  purulent  nasal  discharge        -­‐          Intranasal  drug  use:  Intranasal  cocaine  or  overuse  of  topical  nasal  decongestant,  such  as  oxymetazoline  or  neosynephrine        -­‐        Oral  medications:  Oral  contraceptives,  antithyroid  medication,  antihypertensive  medication,  antidepressants,  and  benzodiazepines     -­‐   Constitutional:  Fever,  Weight  loss,  Loss  of  appetite  

Past  medical  Past  Medical  Conditions:  Asthma  and  obstructive  sleep  apnea,  Wegener’s  granulomatosis,  cystic  fibrosis  (associated  with  nasal  polyposis),  sarcoidosis,  and  syphilis.    Past  Surgeries/Trauma:  rhinoplasty    Past  Hospital  admission  

Social  history  

Nasal block history:

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Household  pets  Smoking,  alcohol  Allergies,  medication,  blood  transfusions.    Family  history  

Asthma,  OSA,  nasal  polyps.  

Infant  

Choanal  atresia/stenosis  

Pyriform  aperture  stenosis  

Child  

Enlarged  adenoids  

Nasal  masses  

Foreign  body  

Adult  

Septal  disorders  (eg,  perforation  due  to  

intranasal  cocaine,  deviation  due  to  trauma)  

Inferior  turbinate  

hypertrophy  

Nasal  polyps  

Nasal  masses  Possible  Discussion  Points:  1.  What’s  your  DDx?  2.  How  will  you  investigate            the  patient?    

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1.  History  of:  -­‐Hx  of  atopy,  URTIs,  enlarged  adenoids,  deviated  septum.  -­‐Recurrent  sinusitis  -­‐Nasal  trauma/  surgery  -­‐Having  household  pets  -­‐Exposure  to  poor  air  quality    2.  Family  history  of  nasal  polyposis.    3.  Use  of  topical  nasal  decongestants  >5  days.  

     

 Congestion,  stuffiness,  or  blockage  within  the  nose,  and/or  difficulty  sleeping/breathing.  

       

In  the  case  of  rhinosinusitis:    +Facial  congestion,  facial  pain  or  pressure,  dysosmia,  rhinorrhea,  postnasal  discharge,  cough,  pruritic  conjunctivitis,  sneezing,  or  throat  irritation/itching.  -­‐Obstructive  Sleep  Apnea.  -­‐Asthma  flare-­‐ups.  -­‐Sinus  infections  and  its  complications.  

       

1.  Anterior  rhinoscopy.  -­‐Performed  with  a  nasal  speculum  or  with  an  otoscope,  along  with  a  bright  light  source  to  improve  visualization.    -­‐Allows  for  optimal  visualization  of  each  vestibule,  the  nasal  turbinates,  septum,  and  mucosal  surfaces.  -­‐Provides  assessment  of  the  size  and  caliber  of  the  inferior  turbinates  and  the  position  of  the  anterior  to  mid-­‐nasal  septum.    -­‐Possible  Findings:            -­‐Occluded  nasal  passageways  caused  by  boggy,  red  nasal  mucosa  may  develop  as  a  result  of  allergies,  nonallergic  rhinitis,  or  overuse  of  nasal  decongestants.              -­‐Ulcerated,  friable  mucosa  may  indicate  granulomatous  disease.              -­‐Polyps  at  the  level  of  the  middle  turbinate  or  mid-­‐nasal  cavity  may  be  visible.            -­‐Purulent  nasal  discharge  is  helpful  in  identifying  cases  of  rhinosinusitis.  2.  Fiberoptic  nasal  endoscopy.    -­‐Posterior  nasal  structures  are  best  visualized  with  nasal  endoscopy.    -­‐Done  after  preparation  of  the  nose  with  topical  decongestant  and/or  topical  anesthetic  spray.  

Investigations

Complications

Signs & Symptoms

Risk Factors

Rhinitis  medicamentosa  (or  RM)  is  a  condition  of  rebound  nasal  congestion  brought  on  by  extended  use  of  topical  decongestants  (e.g.,  oxymetazoline,  phenylephrine,  xylometazoline,  and  naphazoline  nasal  sprays)    

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3.  CT  scan.  4.  Other  testing.  • Allergy  testing    

-­‐should  be  particularly  considered  in  patients  with  concurrent  asthma.  • Acoustic  rhinometry    

-­‐  a  simple,  noninvasive  measure  of  cross-­‐sectional  area  of  the  nasal  cavity  longitudinally  along  the  nasal  passageway.  

• Peak  nasal  airflow    -­‐  a  noninvasive  measure  indicating  peak  nasal  airflow  in  liters  per  minute  achieved  during  maximal  forced  nasal  inspiration.  

• Rhinomanometry    -­‐a  computerized,  functional  assessment  of  airflow.  

Mucosal  biopsy  is  indicated  for  cases  of  suspected  malignancy  and  may  be  helpful  in  the  diagnosis  of  infection  or  inflammatory  disease.  

Depending on the underlying cause.      

Management

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   Definition    Acute  sinusitis:  

• Usually  unilateral  and  after  an  URTI  • Symptoms  usually  last  <4  weeks  

Chronic  sinusitis:  • Pain  is  less  of  a  feature  • Symptoms  last  >3  months  

Fungal  sinusitis:  • Usually  the  patients  are  immunocompromised  due  to  diabetes,  cancer,  HIV,  organ  transplantation  or  using  systemic  or  intranasal  glucocorticoids.  

Presentation    • Presentation  is  often  non-­‐specific  • Nasal  congestion  • Purulent  discharge  • Facial  pain  with  headache  • Dental  pain  (maxillary  sinus)  • Alteration  in  sense  of  smell  • Pain  may  be  exacerbated  by  leaning  forward  or  head  movement  

NB.  Facial  pain  in  the  absence  of  nasal  symptoms  is  unlikely  to  be  sinusitis.  

Complications    • Complications  can  be  life  threatening  • Osteomyelitis  • Orbital  cellulitis  • Intracranial  involvement  

Investigations:  • Diagnosis  depend  on  clinical  history  and  physical  examination.    • Sinuses  culture:  not  for  all  patients  (persistence  infection  despite  antibiotics  treatment  or  immunocompromised).  

• Imaging  may  be  warranted  in  the  case  of  recurrent  episodes  of  sinusitis,  suspected  anatomical  abnormalities,  or  if  an  alternative  diagnosis  is  suspected  such  as  migraine  headache  or  malignancy.  ü Nasal  endoscopy:  mucosal  erythema,  purulent  discharge.  ü CT  Sinuses  (non-­‐contrast):  identifies  extent  of  sinus  disease,  abnormal  

anatomical  structures.  Management:  

• Cases are usually self-limiting • Analgesia and decongestants • Antibiotics • Topical nasal steroids • Surgery: FESS

 Sinusitis:

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Personal  data  (name,age)    Onset    Duration  *   Symptoms  <10  days  (acute  viral  

sinusitis).The  symptoms  usually  peak  early  and  gradually  resolve.    Symptoms  >10  days  but  <4  weeks  (acute  bacterial  sinusitis)  Symptoms  >3  months  (chronic  sinusitis)  

Do  you  have  nasal  obstruction?  *  Unilateral  or  bilateral  *  

Non-­‐specific  symptom  that  may  be  associated  with  viral  or  bacterial  sinusitis  as  well  as  allergic  rhinitis.  

Constant  or  episodic      Discharge  *   Purulent  nasal  discharge  may  be  present  in  

acute  viral  or  bacterial  sinusitis  In  chronic  there  may  be  discolored  rhinorrhea  or  thick  postnasal  drainage  on  the  posterior  pharynx.  

What  makes  your  symptoms  worse?  

 

What  makes  your  symptoms  better?  

 

How  many  times  you  had  previous  episodes  in  the  last  12  months?  *  

Chronic  sinusitis  persistence  mucosal  inflammation  for  >  12  consecutive  weeks  despite  medical  therapy  or  occurrence  of  more  than  4  episodes  a  year.  

Constitutional  symptoms:  Fever?*  

Indicate  presence  of  infection    

Risk  factors  for  Acute  Sinusitis:    Hx  of  Allergic  rhinitis    *   Can  cause  blockage  of  the  sinus  ostium.  Hx  of  viral  URTI   Progress  to  acute  bacterial  sinusitis  Esophageal  reflux  (weak)   It  can  be  mistaken  for  sinusitis.  In  the  

pediatric  population,  it  is  associated  with  chronic  sinusitis.  

Risk  factors  for  chronic  Sinusitis:    Ciliary  dysfunction  *    Aspirin  sensitivity  *   Patients  with  the  triad  of  Samter  (nasal  

polyposis,  aspirin  sensitivity,  and  asthma)  suffer  from  refractory  chronic  sinusitis  

Nasal  obstruction  *   Previous  sinus  surgery    Allergic  rhinitis      

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Severe  mid-­‐septal  deviations    Concha  bullosa  deformity    Paradoxically  bent  middle  turbinates    Foreign  bodies  or  Hx  of  nasal  polyp  Craniofacial  anomalies  

Immunodeficiency    Smoking    hx  asthma    Sarcoidosis   May  affect  the  sinonasal  tract,  causing  

chronic  sinusitis.    

Wegener's  granulomatosis  

Associated  symptoms:  *  

 

Facial  pain/pressure:  Reported  by  the  patient  as  headache  or  discomfort  in  the  anterior  face  or  periorbital  region.  Dental  pain:  Suggests  acute  maxillary  sinusitis  Cough  (common)  Myalgia:  associated  with  acute  viral  sinusitis.  Sore  throat  associated  with  acute  viral  sinusitis.  Hyposmia  (common)  Halitosis  Ear  pain/pressure:  Generalised  mucosal  oedema  causes  blockage  of  auditory  tube  

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Causes:  Epistaxis  is  common  in  children  between  3-­‐10  years  old.  90%  of  epistaxis  cases  are  of  unknown  cause  and  only  10%  can  of  either  local  or  systemic  causes.    

Local  Causes    

Systemic  Causes  

1. Blunt  Trauma.  2. Foreign  body.  3. Inflammatory  Reaction  (acute  

RTIs,  chronic  sinusitis,  allergic  or  environmental  rhinitis)  

4. Anatomical  Deformities  (deviated  septum)  

5. Insufflated  Drugs  (cocaine)  6. Intranasal  Tumors  

(nasopharyngeal  carcinoma  or  angiofibroma)  

 

1. Systemic  Bleeding  Disorders  

2. Atherosclerosis    3. Drugs  (aspirin)  4. Hypertension    5. Vitamin  C  &  K  deficiency    

 Sites:  Anterior  (Little’s  area)  “most  common”  Posterior  (Vicinity  of  sphenopalatine  foramen)    Management:  

• General  measures  “ABCs”  • Stop  the  bleeding  

Ø Digital  pressure.  Ø Cautery  Ø Anterior  nasal  packing  Ø Postnasal  packing  Ø Arterial  ligation      Ø Arterial  embolization    

• Prevent  further  bleeding    

Epistaxis history:

Epistaxis “bleeding from the nose”

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• Introduction.  • Personal  Data.    • Chief  Complaint.    

 History  of  presenting  illness:  

• Side.  • Onset.  • Frequency.  • Duration.  • Color.  • Triggers  “sneezing,  nose  blowing  or  picking”  or  “weather  changes”  • Aggravating  and  relieving  factors.  • Severity  and  estimated  blood  loss.  • Any  previous  episodes.  • Family  history  or  bleeding  disorder.  • Recent  trauma,  URTIs  or  sinusitis.  

 Review  of  Systems:    Ask  about  symptoms  of  excessive  bleeding  (easy  bruising,  bloody  stools,  hemoptysis,  blood  in  urine,  and  excess  bleeding  with  tooth  brushing,  phlebotomy,  or  minor  trauma)  and  symptoms  of  anemia.    Past  Medical  History:  

• Hypertension.  • Coagulopathies  or  any  vascular  abnormalities.  • Cirrhosis,  HIV.  

 Past  Surgical  History:  

• Any  nasal  surgeries.      Medications:  

• Aspirin  or  other  NSAIDs.  • Antiplatelet  drugs  (clopidogrel)  • Aspirin  and  warfarin.  

Social  History:  • Smoking  • Allergies  and  blood  transfusion      

History..

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     Definition:  inflammation  of  the  mucosa  of  the  nasal  cavity  Allergic  Rhinitis:  Common,  IgE  mediated  hypersensitivity  response,  associated  allergic  conjunctivitis  and  asthma  may  occur  

1.  Intermittent  (Seasonal) less  that  4  days/week  or  less  than  4  weeks  at  a  time  2.  Persistent  (Perennial)  4  or  more  days/week  and  4  or  more  weeks    

Clinical  features:  -  Sneezing  may  be  in  paroxysm.  

- Rhinorrhea    -  Nasal  obstruction  and  loss  of  smell  

- Itchiness  of  nose,  palate  

- Tearing,  itching,  redness  of  eyes  

- Burning  sensation  in  the  throat.  

-  Symptom  related  to  asthma    

 Risk  factors:  • Age:  usually  at  childhood    • Family hx : genetic component. • Environmental exposure to allergens :  pollen,  house  dust  mite,  pets  Pathophysiology  phases:  1.  Sensitization  2.  Subsequent  reaction  to  allergen–  early  phase  3.  Late  phase  reaction  4.  Systemic  activation  

Rhinitis:

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Investigations:  1-­‐  Skin  Tests:  it’s  a  primary  tool  in  allergy  investigation.  2-­‐Laboratory  tests:  

-­‐Nasal  cytology,  eosinophil  counts  in  nasal  secretion  -­‐Blood  IgE  level  measurement    (confirmatory  but  it  is  neither  sensitive  nor  specific  )  

Treatment:  •  Prevention:  hygiene  and  avoidance  of  allergen    •  Nasal  irrigation  with  saline    •  Antihistamines    •  Oral  decongestants  (pseudoephedrine)    •  Topical  decongestant    •  Other  topicals:  steroids  (fluticasone,  beclomethazone,),  antihistamines,  and  ipratropium  bromide    •  Oral  steroids  if  severe    •  Desensitization  by  allergen  immunotherapy  •  Surgery:  polypectomy,  Reduction  of  inferior  turbinate  Complications:  Sinusitis,  Otitis  media,  Nasal  polyps,  Sleep  apnea,  Dental  overbite,  Palate  malformations  caused  by  mouth  breathing  Rhinitis  medicamentosa:    Rebound  congestion  due  to  the  overuse  of  intranasal  vasoconstrictors.  For  prevention,  use  of  these  medications  for  only  5-­‐7  d  is  recommended.    *Congestion  reduces  nasal  airflow  and  allows  the  nose  to  repair  itself  (i.e.  washes  away  the  irritants).  Treatment  should  focus  on  the  initial  insult  rather  than  target  this  defense  mechanism.    Vasomotor  Rhinitis    •  Neurovascular  disorder  of  nasal  parasympathetic  system  affecting  mucosal  blood  vessels    •  Nonspecific  reflex  hypersensitivity  of  nasal  mucosa  Caused  by:  -­‐Temperature  change,  Alcohol,  dust,  smoke,  Stress,  anxiety,  neurosis,  hypothyroidism,  pregnancy,  menopause,  Parasympathomimetic  drugs    Clinical  Features:    •  Chronic  intermittent  nasal  obstruction,  varies  from  side  to  side    •  Rhinorrhea:  thin,  watery    •  Mucosa  and  turbinates:  swollen    •  Nasal  allergy  must  be  ruled  out    Treatment:    •  Elimination  of  irritant  factors    

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•  Parasympathetic  blocker    •  Steroids    •  Surgery  (often  of  limited  lasting  benefit):  electrocautery,  cryosurgery,  laser  treatment  or  removal  of  inferior  or  middle  turbinates    •  Symptomatic  relief  with  exercise  (increased  sympathetic  tone)    Infectious  rhinitis  

Specific   Non-­‐specific  

Acute   Common  cold  &  influenza  

-­‐Virus:  rhinovirus,  coronavirus,  adenovirus,  Para  influenza  virus,  respiratory  syncytial  virus,  enterovirus    -­‐Nasal  obstruction:  Pyrexia      -­‐Bacterial:  strep.  Pneumonia,  strept.  Pyogen  *Prophylactic:  avoid  contact  with  patient  *Therapeutic:  Rest,  Analgesics,  Decongestant,  Antibiotic  

Chronic   Syphilis,  Wegner’s  granuloma,  Medline  lethal  granuloma,  Sarcoidosis,  Mycobacteria,  Atrophic  rhinitis    

*Etiology:    -­‐Not  fully  known    -­‐Infection    -­‐Endocrine  or  vitamin  disturbance    *Types:    -­‐Primary  (without  any  interference)    -­‐Secondary  (usually  related  to  surgery)    

 History:  

• What  is  your  main  symptom?  Describe  your  symptom?    

• How  old  were  you  when  you  first  had  these  symptoms?  

• Is  there  anything  that  makes  it  worse?  • What  time  of  year  and  what  time  of  day  do  you  have  these  symptoms?  

• How  much  does  it  bother  you?  How  often  do  you  have  these  symptoms,  and  how  long  do  your  symptoms  last?  

• Do  you  have  trouble  sleeping  or  have  you  missed  school  or  work  because  of  your  symptoms?  

Allergic  rhinitis  traid:  sneezing  +nose  itching+  rhinorrhea    They  may  also  have:  Nasal  or  air  obstruction  

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- Associated  symptoms?  :  See  the  box,  post  nasal  drip,  smell  sensation,  cough  or  throat  clearing,  eye  (itching,  redness,  tearing),  fatigue  and  malaise  (in  children),  Symptoms  of  upper  respiratory  infection  (makes  allergic  etiology  less  likely)    

- Constitutional Symptoms?  Fever,  Weight loss  and  Loss of appetite

•  Symptom  related  to  asthma  (cough,  shortness  off  breath,  wheeze)  

• If  nasal  block:  do  you  need  to  breathe  from  your  mouth?  • If  rhinorrhea:  color?  (Clear  or  colored  may  exist,  though  colored  rhinorrhea  may  indicate  a  co-­‐morbid  disease  process  with  AR)  unilateral  or  bilateral  (uni:  could  be  obstruction  or  foreign  body.  Bi:  could  be  rhinitis  or  sinusitis)  alternating  or  constant  (alternating  is  normal  nasal  cycle)  

• Symptom  related  to  ear  infection?    • Does  anyone  else  in  your  family  have  same  problems,  including  allergic  asthma,  eczema?  

• Do  you  have  other  medical  conditions  that  are  related  to  allergies,  such  asthma,  eczema,  or  rhinitis?  

• Did  you  have  allergies  as  a  child?  Allergy  to  pollen,  house  dust  mite,  food,  pets?    

• What  medicines,  including  over-­‐the-­‐counter  medicines  and  dietary  supplements,  are  you  taking  now?  Do  these  medicines  help  your  symptoms?  

• Have  you  ever  had  surgery  on  your  nose,  throat,  or  ears?   - Social History  :    Smoking or Passive smoking - Alcohol consumption - Traveling

 

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